The debate over the working hours of physicians in training is heating up as requests for public comment on a new proposal that would increase the length of a shift that first-year residents are permitted to work by 12 hours closes next week.

The proposal from the Accreditation Council for Graduate Medical Education would increase the length of each shift a first-year resident is allowed to work from 16 hours to 24 hours, plus an additional 4 hours to “manage transitions in care, promote professionalism, empathy and commitment.” However, first-year residents would still only be permitted to work 80-hour weeks. If implemented, the proposal would change the 16-hour limit the ACGME had approved in 2011. At the time, the consensus was that very junior learners would benefit from a more supported and regulated learning environment, according to a document published by the ACGME.

“With this increased flexibility comes the responsibility for programs and residents to adhere to the 80-hour maximum weekly limit and to utilize flexibility in a manner that optimizes patient safety, resident education, and resident well-being,” Thomas J. Nasca, MD, MACP, CEO of the ACGME, told Healio Family Medicine. “The requirements are intended to support the development of a sense of professionalism by encouraging residents to make decisions based on patient needs and their own well-being, without fear of jeopardizing their program’s accreditation status. In addition, the proposed requirements eliminate the burdensome documentation requirement for residents to justify clinical and educational work hour variations.”

No benefit to reduced hours

Nasca said the ACGME conducted a periodic review of residency program requirements beginning in 2015 and, following that initial review, a task force reviewed published scientific literature that analyzed the impact of standards on the quality and safety of patient care, resident well-being, and resident and fellow clinical care and education hours before coming up with the new proposal.

“The evidence from a number of studies conducted after the 16-hour cap was implemented in 2011 suggested that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” he said.

A study published in JAMA in 2014 analyzed the difference between 30-day mortality rates and 30-day-all-cause readmission rates among Medicare beneficiaries who were hospitalized in teaching hospitals that were known for being either more intensive or less intensive in the care offered. The results demonstrated that there were no significant differences in either outcome in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

“The mission for the original duty hours was an important and well-intended one, which was to decrease the work hours of doctors in training … to improve both patient and physician safety and otherwise improve the overall quality of care,” she said. “Unfortunately, little data have shown a direct benefit in patient outcomes and reduction of medical errors as a result of this change.”

Earlier this year, a study published in The New England Journal of Medicine demonstrated that compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with non-inferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality.

Gamaldo said that as a sleep physician, the evidence is clear that sleep deprivation can have an impact on attention, concentration, critical thinking and fine motor skills. However, she acknowledges that it is not clear if duty hour restrictions translate into doctors in training utilizing the additional time to sleep.

“There is a small amount of data that suggests that sleep time may not have changed, but that this time that was once spent in the hospital is now time that doctors – like many Americans – will exchange instead for other activities of living – including spending time with family and shopping,” she said.

Opening ‘broader discussion’

Janis D. Orlowski, MD, MACP, chief health care officer and director of the Council of Teaching Hospitals and Health Systems at the Association of American Medical Colleges, said the ACGME is proposing a broader discussion on how to ensure physicians are safe and are learning to work over extended hours. She said the documentation includes information about promoting wellness, keeping rested and having support for interns and residents.

“The individual is going to go into a profession where their profession calls on them to work extended hours and to be available at unusual hours,” she said. “We need to train individuals who can learn to pace themselves, who can recognize when they have sleep deprivation or when they are stressed.”

Orlowski said that during her career she has received countless phone calls in the middle of the night, over weekends and during time she might be out with family, but it’s important to learn to develop a technique where an individual can remove themselves from their personal situation. “You have to … become very focused on the individual issue that’s brought to your attention and that is something physicians need to train themselves to do and it makes us better physicians if we can learn to be highly focused, but then also recognize when we need to take a few minutes, or hours, to be at our best.”

Orlowski said that it’s not always necessarily about the number of hours an intern works, but it becomes about “the number of hours you work throughout your life and how you can pace yourself.”

Jessica Vensel Rundo, MD, MS, fellowship program director and a physician within the Sleep Disorders Center at the Cleveland Clinic, also said the increased duty hours will provide a learning opportunity for residents to prepare for a career as a physician.

Vensel Rundo said that in the current medical environment, patients expect greater access to health care.

“Because of this, medical personnel – especially physicians – are expected to be able to care for patients, even when working long hours. Since individuals may be more or less affected by sleep deprivation, it is important for residents to learn early on in their training how much they are affected by lack of sleep. This will allow residents to develop appropriate strategies to combat sleepiness and decreased cognitive functioning when working long hours.”

Vensel Rundo said that acute total sleep deprivation can cause excessive daytime sleepiness, inattention, memory impairment and executive function impairment, but not every individual is the same.

“Certainly, there may be concerns about residents caring for patients when they are sleep-deprived, as their cognitive functioning can be impaired, which could affect clinical judgment,” she said. “However, first-year medical residents always have an upper level resident supervising them, and an attending physician is always available in a supervisory role as well.”

Education opportunities

Not only would the increased hours give first-year residents the real-life setting experience other residents ahead of them have, but it would also give them more time to access educational opportunities, Laurence Katznelson, MD, associate dean of graduate medical education and professor of neurosurgery and medicine at Stanford University School of Medicine, told Healio Family Medicine.

“The current duty hours limit resident access to educational opportunities and the ability to perform appropriate and well performed transitions of care, and, because of both these issues, may worsen burnout,” he said. “First, the proposed changes allow more flexibility for education, by allowing residents to stay longer to care for and maintain continuity in care for patients, as well as to attend both didactic and procedural educational opportunities. Second, the proposal allows flexibility in time for adequate transitions of care, by ensuring that hand-offs are performed in a timely and non-rushed manner … this will reduce patient safety errors. The current hour limits may inadvertently increase in stress and reduce confidence in practice by limiting ability to participate in educational opportunities – such as partaking in surgery for a patient admitted by the resident during the preceding hours – and forcing the resident to rush and insufficiently perform the transitions of care.”

Katznelson said the medical school feels the proposed changes are a correct response to criticisms of the existing limits and that the school feels that the plans for more flexibility in duty hours will improve patient satisfaction by providing more continuity of care.

The medical school would revise its training culture to allow for more flexibility in education if the changes get implemented in July, Katznelson said.

“[We would engage] the surgical specialties to include residents, who are coming off current call limits, to join in the operating room and [ensure] the presence of an appropriate environment to perform transitions of care. We will assure all students and residents that the maximal weekly duty hours will not be altered, and that the rotations will likely be revised weekly to assure maintenance of the duty hour cap.”

In addition, most of the physicians agreed that another benefit of increasing the number of hours would limit the number of handoffs of patients which has been shown to increase confusion and increase medical error.

“There have also been some findings that the increase in hand offs serves as a source of additional stress for the doctors in training as well as the faculty attending’s and the health care team because they feel that they may not know everything about the patient and true ownership of a patient becomes a bit murkier,” Gamaldo said.

Risks of sleep deprivation

However, not every physician supports the proposal. Ronald Chervin, MD, MS, president of the American Academy of Sleep Medicine and director of the University of Michigan Sleep Disorders Center, said that decades of sleep and circadian science provide indisputable evidence that performance is compromised by extended wakefulness.

“Studies have found that cognitive performance and motor skills after being awake between 16 and 24 hours deteriorate to a level that is comparable to being legally drunk,” he said. “Allowing shifts of 24 hours threatens both patient and resident safety by increasing the risk of neurobehavioral and cognitive performance degradation, fatigue-related errors, and injuries to both patients and residents.”

Study results published in the Journal of the Association of American Medical Colleges in 2010 demonstrated through a clinical simulation test that medical interns performed significantly better after working a shortened overnight shift compared with a traditional extended shift.

Chervin noted that the ACGME has identified that residents and faculty members are at an increased risk for burnout, depression and substance abuse, but “the proposed program requirement revisions overlook the fact that sleep deprivation is intimately intertwined with these problems.”

Chervin said that in a letter to the GME community, Nasca noted that the absence of a 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is still their preference.

“The American Academy of Sleep Medicine encourages all residency program directors to limit their resident physician work hours to a maximum shift of 16 hours, which we believe is the optimal limit to ensure both adequate resident education and the safety of patients and physicians,” he said.

The physicians who do support the increase acknowledged that added supervision is critical to ensuring there is no burnout or increase in errors.

“I certainly agree that continued efforts to monitor the vitality, alertness and overall health of the health care provider is critical, which includes ongoing efforts to prioritize assessments of sleepiness and fatigue,” Gamaldo said.

In addition, Gamaldo said she appreciated that the proposal specifically mentions clinicians should be afforded time if they need to rest.

“If a resident after 6 hours or 8 hours, needs to be able to say to the team, ‘It’s been a long 6 hours I need to go take a nap, I need to go and just do some meditation.’ … we need to have mechanisms in place and we need to support individuals to be able to take individual time and we need to train people to do that,” Orlowski said.

Public comment closes on December 19 with the task force expected to vote in February. – by Ryan McDonald

The debate over the working hours of physicians in training is heating up as requests for public comment on a new proposal that would increase the length of a shift that first-year residents are permitted to work by 12 hours closes next week.

The proposal from the Accreditation Council for Graduate Medical Education would increase the length of each shift a first-year resident is allowed to work from 16 hours to 24 hours, plus an additional 4 hours to “manage transitions in care, promote professionalism, empathy and commitment.” However, first-year residents would still only be permitted to work 80-hour weeks. If implemented, the proposal would change the 16-hour limit the ACGME had approved in 2011. At the time, the consensus was that very junior learners would benefit from a more supported and regulated learning environment, according to a document published by the ACGME.

“With this increased flexibility comes the responsibility for programs and residents to adhere to the 80-hour maximum weekly limit and to utilize flexibility in a manner that optimizes patient safety, resident education, and resident well-being,” Thomas J. Nasca, MD, MACP, CEO of the ACGME, told Healio Family Medicine. “The requirements are intended to support the development of a sense of professionalism by encouraging residents to make decisions based on patient needs and their own well-being, without fear of jeopardizing their program’s accreditation status. In addition, the proposed requirements eliminate the burdensome documentation requirement for residents to justify clinical and educational work hour variations.”

No benefit to reduced hours

Nasca said the ACGME conducted a periodic review of residency program requirements beginning in 2015 and, following that initial review, a task force reviewed published scientific literature that analyzed the impact of standards on the quality and safety of patient care, resident well-being, and resident and fellow clinical care and education hours before coming up with the new proposal.

“The evidence from a number of studies conducted after the 16-hour cap was implemented in 2011 suggested that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” he said.

A study published in JAMA in 2014 analyzed the difference between 30-day mortality rates and 30-day-all-cause readmission rates among Medicare beneficiaries who were hospitalized in teaching hospitals that were known for being either more intensive or less intensive in the care offered. The results demonstrated that there were no significant differences in either outcome in the year after implementation of the 2011 ACGME duty hour reforms compared with those hospitalized in the 2 years before implementation.

“The mission for the original duty hours was an important and well-intended one, which was to decrease the work hours of doctors in training … to improve both patient and physician safety and otherwise improve the overall quality of care,” she said. “Unfortunately, little data have shown a direct benefit in patient outcomes and reduction of medical errors as a result of this change.”

Earlier this year, a study published in The New England Journal of Medicine demonstrated that compared with standard duty-hour policies, flexible, less-restrictive duty-hour policies for surgical residents were associated with non-inferior patient outcomes and no significant difference in residents’ satisfaction with overall well-being and education quality.

Gamaldo said that as a sleep physician, the evidence is clear that sleep deprivation can have an impact on attention, concentration, critical thinking and fine motor skills. However, she acknowledges that it is not clear if duty hour restrictions translate into doctors in training utilizing the additional time to sleep.

“There is a small amount of data that suggests that sleep time may not have changed, but that this time that was once spent in the hospital is now time that doctors – like many Americans – will exchange instead for other activities of living – including spending time with family and shopping,” she said.

Opening ‘broader discussion’

Janis D. Orlowski, MD, MACP, chief health care officer and director of the Council of Teaching Hospitals and Health Systems at the Association of American Medical Colleges, said the ACGME is proposing a broader discussion on how to ensure physicians are safe and are learning to work over extended hours. She said the documentation includes information about promoting wellness, keeping rested and having support for interns and residents.

“The individual is going to go into a profession where their profession calls on them to work extended hours and to be available at unusual hours,” she said. “We need to train individuals who can learn to pace themselves, who can recognize when they have sleep deprivation or when they are stressed.”

Orlowski said that during her career she has received countless phone calls in the middle of the night, over weekends and during time she might be out with family, but it’s important to learn to develop a technique where an individual can remove themselves from their personal situation. “You have to … become very focused on the individual issue that’s brought to your attention and that is something physicians need to train themselves to do and it makes us better physicians if we can learn to be highly focused, but then also recognize when we need to take a few minutes, or hours, to be at our best.”

Orlowski said that it’s not always necessarily about the number of hours an intern works, but it becomes about “the number of hours you work throughout your life and how you can pace yourself.”

Jessica Vensel Rundo, MD, MS, fellowship program director and a physician within the Sleep Disorders Center at the Cleveland Clinic, also said the increased duty hours will provide a learning opportunity for residents to prepare for a career as a physician.

Vensel Rundo said that in the current medical environment, patients expect greater access to health care.

“Because of this, medical personnel – especially physicians – are expected to be able to care for patients, even when working long hours. Since individuals may be more or less affected by sleep deprivation, it is important for residents to learn early on in their training how much they are affected by lack of sleep. This will allow residents to develop appropriate strategies to combat sleepiness and decreased cognitive functioning when working long hours.”

Vensel Rundo said that acute total sleep deprivation can cause excessive daytime sleepiness, inattention, memory impairment and executive function impairment, but not every individual is the same.

“Certainly, there may be concerns about residents caring for patients when they are sleep-deprived, as their cognitive functioning can be impaired, which could affect clinical judgment,” she said. “However, first-year medical residents always have an upper level resident supervising them, and an attending physician is always available in a supervisory role as well.”

Education opportunities

Not only would the increased hours give first-year residents the real-life setting experience other residents ahead of them have, but it would also give them more time to access educational opportunities, Laurence Katznelson, MD, associate dean of graduate medical education and professor of neurosurgery and medicine at Stanford University School of Medicine, told Healio Family Medicine.

“The current duty hours limit resident access to educational opportunities and the ability to perform appropriate and well performed transitions of care, and, because of both these issues, may worsen burnout,” he said. “First, the proposed changes allow more flexibility for education, by allowing residents to stay longer to care for and maintain continuity in care for patients, as well as to attend both didactic and procedural educational opportunities. Second, the proposal allows flexibility in time for adequate transitions of care, by ensuring that hand-offs are performed in a timely and non-rushed manner … this will reduce patient safety errors. The current hour limits may inadvertently increase in stress and reduce confidence in practice by limiting ability to participate in educational opportunities – such as partaking in surgery for a patient admitted by the resident during the preceding hours – and forcing the resident to rush and insufficiently perform the transitions of care.”

Katznelson said the medical school feels the proposed changes are a correct response to criticisms of the existing limits and that the school feels that the plans for more flexibility in duty hours will improve patient satisfaction by providing more continuity of care.

The medical school would revise its training culture to allow for more flexibility in education if the changes get implemented in July, Katznelson said.

“[We would engage] the surgical specialties to include residents, who are coming off current call limits, to join in the operating room and [ensure] the presence of an appropriate environment to perform transitions of care. We will assure all students and residents that the maximal weekly duty hours will not be altered, and that the rotations will likely be revised weekly to assure maintenance of the duty hour cap.”

In addition, most of the physicians agreed that another benefit of increasing the number of hours would limit the number of handoffs of patients which has been shown to increase confusion and increase medical error.

“There have also been some findings that the increase in hand offs serves as a source of additional stress for the doctors in training as well as the faculty attending’s and the health care team because they feel that they may not know everything about the patient and true ownership of a patient becomes a bit murkier,” Gamaldo said.

Risks of sleep deprivation

However, not every physician supports the proposal. Ronald Chervin, MD, MS, president of the American Academy of Sleep Medicine and director of the University of Michigan Sleep Disorders Center, said that decades of sleep and circadian science provide indisputable evidence that performance is compromised by extended wakefulness.

“Studies have found that cognitive performance and motor skills after being awake between 16 and 24 hours deteriorate to a level that is comparable to being legally drunk,” he said. “Allowing shifts of 24 hours threatens both patient and resident safety by increasing the risk of neurobehavioral and cognitive performance degradation, fatigue-related errors, and injuries to both patients and residents.”

Study results published in the Journal of the Association of American Medical Colleges in 2010 demonstrated through a clinical simulation test that medical interns performed significantly better after working a shortened overnight shift compared with a traditional extended shift.

Chervin noted that the ACGME has identified that residents and faculty members are at an increased risk for burnout, depression and substance abuse, but “the proposed program requirement revisions overlook the fact that sleep deprivation is intimately intertwined with these problems.”

Chervin said that in a letter to the GME community, Nasca noted that the absence of a 16-hour limit does not imply that programs may no longer configure their clinical schedules in 16-hour increments if that is still their preference.

“The American Academy of Sleep Medicine encourages all residency program directors to limit their resident physician work hours to a maximum shift of 16 hours, which we believe is the optimal limit to ensure both adequate resident education and the safety of patients and physicians,” he said.

The physicians who do support the increase acknowledged that added supervision is critical to ensuring there is no burnout or increase in errors.

“I certainly agree that continued efforts to monitor the vitality, alertness and overall health of the health care provider is critical, which includes ongoing efforts to prioritize assessments of sleepiness and fatigue,” Gamaldo said.

In addition, Gamaldo said she appreciated that the proposal specifically mentions clinicians should be afforded time if they need to rest.

“If a resident after 6 hours or 8 hours, needs to be able to say to the team, ‘It’s been a long 6 hours I need to go take a nap, I need to go and just do some meditation.’ … we need to have mechanisms in place and we need to support individuals to be able to take individual time and we need to train people to do that,” Orlowski said.

Public comment closes on December 19 with the task force expected to vote in February. – by Ryan McDonald